Sepsis

Introduction:

Sepsis is a clinical syndrome resulting from severe infection and activation of the systemic inflammatory response. It is characterized by immune dysregulation leading to a generalized pro-inflammatory cascade, microcirculatory derangements, and end-organ dysfunction. It is typically this dysregulated immune response, and not the infectious organism itself, that is responsible for multiple organ failure and adverse outcomes in sepsis.

Early recognition of sepsis is crucial to ensuring the best outcomes in children, as it is the leading cause of morbidity and mortality in children worldwide.

Epidemiology:

The overall global burden of sepsis is high, however the global incidence varies by region. Approximately 6-8% of patients were treated in a pediatric intensive care unit (PICU) for sepsis in North America, Europe, Australia and New Zealand, with an overall mortality of 21-32%. An estimated 15% of patients were treated for sepsis in PICUs in Asia and South America, with mortality rates of 40% and 11%, respectively. Similarly, about 25% were treated in PICUs in Africa with a mortality of 40%.

In the U.S., it has been approximated that there are over 42,000 cases of pediatric severe sepsis per year nationally (0.56 cases per 1,000 population per year).

Respiratory and blood infections are found in about two-thirds of sepsis cases worldwide, many of which are due to infections that are preventable by vaccines.

Risk Factors:

Age less than one month: Infants are at highest risk, especially those with a low birth weight

Chronic debilitating medical condition

Host immunosuppression

Serious injury

Large surgical incisions

Invasive devices (Foley catheters, chest tubes, etc.)

Recurrent UTIs due to urinary tract abnormalities

Pathogens:

Sepsis can be caused by bacterial, viral, fungal, parasitic, or rickettsial infections, with bacteria and viruses being the most common. The typical or important pathogens in sepsis are:

Clinical Presentation:

In general, sepsis should be suspected in any acute illness or in neonates if there is any change in the patient’s normal pattern of behavior. The diagnosis oftentimes is made using clinical judgment, since diagnostic criteria are primarily considered research criteria. Thus, a clinician should consider sepsis or septic shock if a child has a suspected or proven infection and has at least 2 of the following:

Core temperature <36° C or >38.5° C (<97° F or >101° F).

Inappropriate tachycardia (according to local criteria or advanced pediatric life support guidance).

Management:

Sepsis management requires quick recognition and special attention must be paid to educate and train all healthcare staff to enable appropriate triage and rapid treatment. Particular emphasis on early administration of antibiotics and fluid resuscitation is vital.

Consensus guidelines are available online through the Pediatric Sepsis Initiative. The Pediatric Advanced Life Support (PALS) Pocket Reference Card provides a summary algorithm. A general sequence for recognition and treatment is:

Recognize signs of poor perfusion.

Assess ABCs.

Establish IV access and place patient on monitor.

Fluid and electrolyte resuscitation.

Infection control.

Supplemental therapies.

Therapeutic endpoints include:

Normalized heart rate

Capillary refill <2 sec

Normal pulse quality

Warm extremities

Normalized blood pressure

Normal mental status

Urine output >1 mL/kg/hr.

No difference in peripheral and central pulses

Decreasing lactate

SvO2>70%

CVP>8 mmHg

Prognosis:

Severe sepsis, without treatment, has a mortality of more than 80%. With treatment, it is decreased to about 10% in children up to 19 years of age, with no difference in gender. Those with a pre-existing condition have a mortality of around 13% compared to 7% in previously healthy children.

Early recognition of sepsis and resuscitation, according to ACCM-PALS guidelines, resulted in a mean length of stay of 5.5 days in the intensive care unit and a mean length of stay of 8 days in the hospital.